Transfemoral Procedures Research Articles

Early Endocarditis and Delayed Left Ventricular Pseudoaneurysm Complicating a Transapical Transcatheter Mitral Valve-in-Valve Implantation: Percutaneous Closure Under Local Anesthesia and Echocardiographic Guidance.

A 72-year-old man was referred because of suspected infective endocarditis. Fifteen years earlier, he had undergone mitral valve replacement with a 33-mm Hancock valve for severe mitral regurgitation. Three months ago, he presented with a first episode of congestive heart failure caused by severe mitral regurgitation reflecting degeneration of the bioprosthetic valve without sign of endocarditis. Because of a high surgical risk based on an estimated Euroscore I of 42.96% and The Society of Thoracic Surgeons (STS) score of 29% (main comorbidity is an advanced Parkinson disease), valve-in-valve implantation was planned. A 29-mm Edwards Sapien 3 (S3) balloon-expandable valve was successfully implanted through transapical puncture of the left ventricle (LV) after direct surgical exposure by mini thoracotomy. Patient was discharged 10 days after the procedure without complications. On his admission, the patient was febrile and examination revealed a purulent discharge at the site of thoracotomy. Transthoracic echocardiography (TTE) and transesophageal echocardiography showed a 15-mm mobile vegetation on the leaflet of the S3 (Movie I in the Data Supplement) and a pseudoaneurysm at the apex of the left ventricle (LVPA) flowing by a large apical defect (Figure 1; Movie II in the Data Supplement). Computed tomographic (CT) scanning confirmed the LVPA free from any thrombus and identified the surgical suture tip in its deep (Figures 1 and 2; Movie III in the Data Supplement). 18F positron-emission tomography demonstrated an uptake on the S3 and LVPA (Figure 2). Blood cultures were positive for Staphylococcus aureus . Antibiotherapy with co-trimoxazole for 6 weeks and clindamycin for 1 week was started, and a quick clinical and biological …

Local Versus General Anesthesia in Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) is conventionally performed under general anesthesia (GA) allowing intraoperative transoesophageal echocardiogram imaging. We present our experience in patients having the procedure under local anesthesia (LA), who were subsequently transferred to a low dependency unit postprocedure, to assess safety and length of hospital stay. We retrospectively assessed all the transfemoral TAVR procedures conducted at our center from January 03, 2011. Of 216 patients, 145 had the procedure under GA and 71 under LA. Both groups were similar with respect to age, co-morbidities, Euro Score, and the severity of the aortic stenosis. The procedure time was significantly shorter in the LA group measured from time in room to skin closure (108 vs 143minutes, p <0.001). Skin open to skin closure time were the same in both groups (78 vs 79.4minutes, p= 0.57). There was no difference in 30days: aortic regurgitation > mild (2.1% in GA and 2.8% in LA, p= 0.67), need for permanent pacing (3.4% in GA and 1.4% in LA, p= 0.32), and disabling cerebrovascular accidents (1.4% and 1.4%, p= 1.0). The 30-day survival was not significantly different (95.9% in GA and 100% in LA, p= 0.17), whereas the median number of days in hospital was shorter in the LA group (4 in GA and 2 in LA, p <0.001). No emergency conversions to GA were performed in the LA group and only 1 patient needed admission to a high dependency (HD) unit. In conclusion, performing a TAVR under LA is at least as safe as GA. In addition, there is a reduced procedural time and length of hospital stay. LA is a safe and cost-effective alternative to GA and patients can be safely transferred to a low dependency unit.

Clinical outcomes of transcatheter aortic valve implantation: from learning curve to proficiency

ObjectiveThe use of transcatheter aortic valve implantation (TAVI) is growing rapidly in countries with a predominantly elderly population, posing a huge challenge to healthcare systems worldwide. The increment of human...

19 Local versus general anaesthesia in transcatheter aortic valve replacement – a tertiary centre experience

Introduction TAVR is conventionally performed under general anaesthesia (GA) allowing intraoperative TOE imaging. We present our experience in patients having the procedure under local anaesthesia (LA) to assess safety and length of hospital stay. Methods We retrospectively assessed all the transfemoral TAVR procedures conducted at our centre from 01/03/2011. Of 216 patients, 145 had the procedure under GA and 71 under LA. Results Both groups were similar with respect to age (80.2 vs 80.9), comorbidities, Euro Score (18.5 vs 18.8) and the severity of the aortic stenosis (AVA 0.66 vs 0.67cm2, mean/peak gradient 45.5 vs 44.2, 77.1 vs 74.5mmHg). The procedure time was significantly shorter in the LA group measured from time in room to skin closure (108 mins v 143 mins; p mild (2.1% in GA and 2.8% in LA; p = 0.744), need for permanent pacing (2.3% in GA and 1.4% in LA; P = 0.617), and cerebrovascular accidents (1.4% and 1.4%, p = 0.986). The 30 day survival was significantly different (96.5% in GA and 100% in LA; P = 0.023) as was the mean number of days in hospital (7.1 in GA and 4.6 in LA; P Conclusions Performing a TAVR under LA is at least as safe as GA. In addition there is a reduced procedural time and length of hospital stay. LA is a safe and cost effective alternative to GA.

Nitinol clip distal migration and resultant popliteo-tibial artery occlusion complicating access closure by the StarClose SE vascular closure system

Lower extremity ischemia following deployment of a vascular closure device for access site closure after a transfemoral endovascular procedure rarely occurs. A 68-year-old woman diagnosed with subarachnoid hemorrhage due to...

EuroSCORE II and STS as mortality predictors in patients undergoing TAVI.

the EuroSCORE II and STS are the most used scores for surgical risk stratification and indication of transcatheter aortic valve implantation (TAVI). However, its role as a tool for mortality prediction in patients undergoing TAVI is still unclear. to evaluate the performance of the EuroSCORE II and STS as predictors of in-hospital and 30-day mortality in patients undergoing TAVI. we included 59 symptomatic patients with severe aortic stenosis that underwent TAVI between 2010 and 2014. The variables were analyzed using Student's t-test and Fisher's exact test and the discriminative power was evaluated using receiver operating characteristic curve (ROC) and area under the curve (AUC) with a 95% confidence interval. mean age was 81±7.3 years, 42.3% men. The mean EuroSCORE II was 7.6±7.3 % and STS was 20.7±10.3%. Transfemoral procedure was performed in 88.13%, transapical in 3.38% and transaortic in 8.47%. In-hospital mortality was 10.1% and 30-day mortality was 13.5%. Patients who died had EuroSCORE II and STS higher than the survivors (33.7±16.7vs. 18.6±7.3% p=0,0001 for STS and 13.9±16.1 vs. 4.8±3.8% p=0.0007 for EuroSCORE II). The STS showed an AUC of 0.81 and the EuroSCORE II of 0.77 and there were no differences in the discrimination ability using ROC curves (p=0.72). in this cohort, the STS and EuroSCORE II were predictors of in-hospital and 30-days mortality in patients with severe aortic stenosis undergoing TAVI.

Abstract 15240: Cholesterol Crystal Embolization: The Incidence as a Cardiac Procedural Complication and the Comparison of the Outcomes Between its Causes

Background: Cholesterol crystal embolization (CCE) is very rare, but has a poor prognosis and no proven therapy. Although CCE occurs from various causes, the incidence and outcomes of CCE remain unclear. Purpose: 1) to investigate the incidence of CCE as a complication of percutaneous coronary intervention (PCI), percutaneous transluminal angioplasty (PTA), and cardiovascular surgery; and 2) to investigate patient characteristics and outcomes of CCE on the basis of its causes: idiopathic CCE, catheter-related CCE, and cardiovascular surgery-related CCE. Methods: We registered 75 patients having CCE in the medical records between May 2004 and April 2014 and compared their patient characteristics and outcomes according to the causes of CCE: idiopathic CCE, 31 patients (41%); catheter-related CCE, 32 (43%); and cardiovascular surgery-related CCE, 12 (16%). CCE was diagnosed by clinical findings (blue toe syndrome or livedo) or laboratory findings (elevated serum creatinine level, eosinophil count, or skin biopsy). Results: The incidences of catheter-related CCE were 0.7% in PTA on arteriosclerotic obliterans and 0.17% in PCI. The incidence of CCE after PCI was significantly higher in patients treated with femoral approach than in those treated with nonfemoral approach (0.32% vs. 0.01%, p&lt;0.001). The incidences of cardiovascular surgery-related CCE were relatively high in endovascular aortic repair (1.3%) and in abdominal aortic replacement (0.6%). In the comparison of patient characteristics between idiopathic CCE, catheter-related CCE, and cardiovascular surgery-related CCE, there were significant differences in age and aortic aneurysm. Of the 75 patients, 24 (32%) died, 10 (13%) initiated dialysis, and 7 (9%) underwent leg or toe amputation. There was no significant difference in the outcomes of CCE depending on its causes. Conclusion: The incidences of CCE were significantly high in transfemoral procedures and in surgery for abdominal aortic aneurysm. Between the causes of CCE, there were significant differences in patient characteristics, but no significant differences in the outcomes.

Intermediate Clinical and Hemodynamic Outcomes After Transcatheter Aortic Valve Implantation

Concerns still exist regarding long-term results and freedom from valve-related adverse events in transcatheter aortic valve implantation (TAVI). The aim of this single-center retrospective study was to assess intermediate-term (up to 5-year) clinical and hemodynamic outcomes in patients undergoing TAVI. From 2007 through 2013, 338 consecutive patients underwent TAVI at our institution. Preoperative variables were defined according to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) definitions, and outcomes were reported according to the Valve Academic Research Consortium (VARC)-2 definitions. Multivariate logistic regression analysis was performed to identify independent predictors of mortality at follow-up. transfemoral (TF) and transapical (TA) TAVI were performed in 233 (69%) and 105 (31%) patients, respectively. All-cause 30-day mortality was 4.4%, with no differences between TA and TF procedures. Thirty-day cardiovascular death, stroke, and myocardial infarction were not different between groups. The acute kidney injury (AKI) rate was higher in the TA group (30.5% versus 11.2%; p < 0.001). Access-related complications were more frequent in the TF group (36.1% versus 11.4%; p < 0.001). Mean follow-up was 22.3 ± 17.8 months (range, 1-74 months). Overall survival rates at 1, 3, and 5 years were 85.5% ± 2.1%, 69.9% ± 3.2%, and 61% ± 4.3%, respectively. Independent predictors of all-cause mortality at follow-up were previous myocardial infarction (odds ratio [OR], 2.7), any grade of paravalvular leak (PVL) (OR, 2.5), and AKI (OR, 3.1). Mean gradient and effective orifice area at follow-up were 10.7 ± 12.0 mm Hg and 1.1 ± 0.9 cm(2)/m(2), respectively. Our data show that TAVI has good early and intermediate-term clinical and hemodynamic outcomes in high-risk or inoperable patients with severe symptomatic aortic valve stenosis. PVL of any grade has a significant impact on survival.

The tricky charm of the radial access.

The tricky charm of the radial access.

OUTCOMES FOLLOWING TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI) IN ONTARIO (2007-2013)

The Cardiac Care Network of Ontario (CCN) works to plan, coordinate, implement and evaluate adult cardiovascular care in Ontario, and is responsible for maintaining the CCN Cardiac Registry. Transcatheter Aortic Valve Implantation (TAVI) is a transcatheter procedure to replace diseased aortic valves, without the need for open heart surgery. Ten (10) hospitals in Ontario provide TAVI procedures. All 10 hospitals enter data in the CCN Cardiac Registry. All TAVI procedures in the CCN Cardiac Registry between January 2007 and November 2013 were analyzed. Patient characteristics and procedural details were obtained from the CCN Cardiac Registry. Data from the CCN Cardiac Registry was linked to the Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD) and the Ontario Registered Persons Database (RPDB) to calculate post-procedural outcomes. The primary outcomes measured were crude unadjusted all-cause mortality and readmission rates and were calculated at varying time points, out to 3-years post-procedure. A secondary analysis was performed focusing on outcomes for more recent TAVI procedures (January 2010 to November 2013). This study was developed by CCN, with data analysis completed by the Institute for Clinical Evaluative Sciences. A total of 1,105 unique TAVI procedures were identified and linked to the CIHI-DAD and RPDB. Analysis of TAVI procedures in Ontario revealed that the majority of procedures performed were done via femoral access (73.7%). In-hospital mortality was found to be 6.2% overall with rates being lower for transfemoral procedures (4.2%) versus non-transfemoral (11.7%). At 1-year post-procedure the overall all-cause mortality rate was 19.4% with an all-cause readmission rate of 49.3%. At 3-years post-procedure, the overall all-cause mortality rate was 43.9% with an all-cause readmission rate of 74.7%. Overall, mortality rates in Ontario following TAVI procedures are comparable to rates reported by other jurisdictions. Although all-cause mortality and readmission rates at 3-years are high, this may be explained by comorbidities and frailty in the TAVI patient population, as well as the fact this registry covers the early experience for most centres. In general we believe based on these outcomes that TAVI is a relatively safe and effective procedure to treat aortic stenosis in patients who are at extreme or high risk for conventional cardiac surgery in Ontario. CCN will continue to report on outcomes following TAVI procedures in Ontario to ensure that all Ontarians have access to the highest possible quality of cardiac care.

Influence of different approaches of aortic valve replacement on the incidence of post-operative delirium in intermediate risk patients – a matched pair analysis

Objectives:Evaluation of the risk for post-operative delirium (POD) after surgical or transfemoral aortic valve replacement (AVR) as an additional decision parameter for the choice of treatment in patients with an EuroScore (ES) between 10% and 20%.Background:POD is well known as a not infrequent side effect of cardiac surgery necessitating extracorporeal circulation. In Germany a tendency to treat patients with ES <20% with transfemoral AVR (TF) instead of surgical AVR (SAVR) was observed in 2013. The risk of POD may influence the decision of physician and patient as to which procedure would be appropriate in the individual case. Therefore we performed an analysis of the incidence of POD in patients with comparable risk treated either with surgical or transfemoral aortic valve replacement.Methods:Patients with elective or urgent need for AVR and EuroScore between 10% and 20% were extracted from the database of all isolated AVR procedures in Germany of 2013. As a result 3407 cases, 771 SAVR patients and 2636 TF patients with EuroScore 10–20%, were extracted from the complete data-base of the German quality insurance registry for heart surgery. Two homogeneous groups with regard to the risk predicted by ES were built by case–control matches and compared for available variables. In a second step two groups with identical risk/co-morbidity profile for 10 variables were identified and analyzed with respect to POD and in-hospital mortality.Results:A total of 763 pairs with EuroScore of 13.5% each could be determined. Mean age was 75.6 years (SAVR, 51.6% male) and 78.8 years (TF, 56.5% male). Incidence of POD with need for therapy (POD-T) was 12.8% after SAVR and 3.8% after TF, resulting in numbers needed to harm of 8 and 26 respectively. In-hospital death rate of patients with POD-T was 5.1% after SAVR and 3.3% after TF, and nearly identical compared with patients without POD-T. POD-T had a negative influence on the regular discharge procedure. Further matching resulted in two groups of 470 patients each with identical co-morbidities and an age difference of 1 year but POD-T rates of 14.5% (SAVR) and 4.9% (TF); in-hospital mortality was 6.2% (SAVR) and 2.3% (TF).Limitations:The dataset contains valid data only for the period of hospital stay until discharge. Therefore conclusions about the duration and reversibility of POD, which are important parameters of quality of life and resource consumption as well as midterm consequences, cannot be estimated. The documentation of the German Federal Council asks only for POD and POD-T, a predefined definition of POD is not given; this may have some influence on the data. We therefore confined the analysis to only POD-T. In addition only a limited number of co-morbidities are documented.Conclusion:In patients with intermediate risk according to EuroScore (10–20%) the risk of post-operative delirium and in-hospital mortality is significantly higher after surgical aortic valve replacement than after transfemoral procedure. This may be considered for patient guidance and the decision as to which procedure is able to achieve the best result including minimizing side effects.

Major femoral vascular access complications after coronary diagnostic and interventional procedures: A Danish register study

BackgroundVascular access complications after coronary angiography (CAG) and percutaneous coronary intervention (PCI) are known to increase morbidity, prolong hospitalization and raise hospital costs. Therefore, risk factor identification and improvement of safety strategies for vascular management are important. We aimed to assess the incidence of major vascular complications related to femoral access, and to identify potential risk factors. MethodsOver a period of six years, 23,870 index procedures (CAG) were performed in two centres, prospectively entered in the database and retrospectively analysed. Data was obtained from the Eastern Danish Heart Registry and cross-matched with data from the Danish Vascular Registry. Index procedures were defined as the first trans-femoral procedure. Demographic, procedural and mortality data, as well as information on access complications requiring surgery within 30days were collected. Mortality data were collected for minimum 12months. ResultsWe identified 130 (0.54%) access complications requiring surgery; 65 pseudoaneurysms (0.28%), 46 arterial occlusions (0.19%), 15 hematomas (nine groin and six retroperitoneal hematomas) (0.06%), and 4 arterial dissections (0.02%). Risk factors for complications were left sided femoral access (OR 4.11 [2.29–7.37] p<0.001), peripheral arterial disease (PAD) (OR 2.42 [1.48–3.94] p<0.0001) and female sex (OR 2.22 [1.51–3.24] p<0.0001). ConclusionVascular complications related to femoral access in coronary diagnostic and interventional procedures are low (0.54%). Risk factors were left sided access, PAD, and female sex.

Intra-Aortic Balloon Pump Malposition Reduces Visceral Artery Perfusion in an Acute Animal Model.

Visceral artery perfusion can be potentially affected by intra-aortic balloon pump (IABP) catheters. We utilized an animal model to quantify the acute impact of a low balloon position on mesenteric artery perfusion. In six pigs (78 ± 7 kg), a 30-cc IABP was placed in the descending aorta in a transfemoral procedure. The celiac artery (CA) and the cranial mesenteric artery (CMA) were surgically dissected. Transit time blood flow was measured for (i) baseline, (ii) 1:1 augmentation with the balloon proximal to the visceral arteries, and (iii) 1:1 augmentation with the balloon covering the visceral arteries. Blood flow in the CMA and CA was reduced by 17 and 24%, respectively, when the balloon compromised visceral arteries compared with a position above the visceral arteries (flow in mL/min: CMA: (i) 1281 ± 512, (ii) 1389 ± 287, (iii) 1064 ± 276, P < 0.05 for 3 vs. 1 and 3 vs. 2; CA: (i) 885 ± 370, (ii) 819 ± 297, (iii) 673 ± 315; P < 0.05 for 3 vs. 1). The covering of visceral arteries by an IABP balloon causes a significant reduction of visceral artery perfusion; thus, the positioning of this device during implantation is critical for obtaining a satisfactory outcome.

Occurrence of femoral nerve injury among patients undergoing transfemoral percutaneous catheterization procedures in United States (P4.307)

Occurrence of femoral nerve injury among patients undergoing transfemoral percutaneous catheterization procedures in United States (P4.307)

Multicenter evaluation of transcatheter aortic valve replacement using either SAPIEN XT or CoreValve: Degree of device oversizing by computed-tomography and clinical outcomes.

To analyze the association between computed-tomography-derived degrees of device oversizing and clinical outcomes during transcatheter aortic valve replacement (TAVR). Previous reports suggest that different devices reach optimal results with different degrees of device oversizing. Therefore, similar sized devices of different types (SAPIEN XT and CoreValve) may be favored in different annular ranges and a case considered borderline between two sizes of a specific device might be within a favorable range of another. A multicenter registry of 615 consecutive transfemoral TAVR procedures using either SAPIEN XT or CoreValve was analyzed. A first group of 190 patients had annular sizes for which only moderate oversizing degree was feasible (5-20% by area or 2.5-9.5% by perimeter). A second group included 178 patients that had annulus size for which only large oversizing degree was feasible (20.1-35% by area or 9.6-16.2% by perimeter). In the "only large oversizing feasible group" there were more annular rupture events in patients treated by SAPIEN XT valve as compared to those treated by CoreValve (3.4% vs. 0%, P = 0.04). In the "only moderate oversizing feasible group", those treated by CoreValve had more post balloon dilatation and 30-day major stroke in comparison with those treated by SAPIEN XT (16.1% vs. 7.7%, P = 0.04 and 8% vs. 1.3%, P = 0.02, respectively). Optimal clinical performance of CoreValve and SAPIEN XT appears to be reached with different degrees of oversizing. Certain annular sizes that allow for only moderate or large oversizing, but not both, appear to benefit from a device specific approach.

Evaluation of a Structured Training Program for Arterial Femoral Sheath Removal After Percutaneous Arterial Catheter Procedures by Assistant Personnel

After cardiac catheterization procedures, arterial closure can be achieved by manual compression (MC), using external mechanical compression devices, or by applying vascular closure devices (VCDs) with comparable vascular access site-related complication rates. The aim of the present study was to assess vascular access site-related complications during the implementation of structured sheath removal and MC by paramedics after catheterization procedures. After an observational phase of 3 months to assess the baseline complication rate, a structured 4-level training program was implemented to train assistant personnel, in this case paramedics, in the management of sheath removal by MC. Access site-related complication rates after sheath removal were assessed prospectively and MC by paramedics compared with MC by physicians and application of VCDs. To account for imbalances in procedure- and patient-related risk factors of access-site complications, propensity score-based matching analysis was performed (ClinicalTrials.gov identifier NCT00825331). All consecutive percutaneous transfemoral arterial cardiac catheterization procedures were prospectively assessed over a period of 8 months (n = 3,503). MC was performed in 2,315 cases, of which 180 were performed by paramedics and 2,135 by physicians; VCDs were applied in 1,188 procedures. Rates of access site-related complications were significantly lower for paramedics compared with physicians (p = 0.03) and similar between paramedics and VCDs (p = 0.77). In conclusion a structured program for paramedics to be trained in sheath removal after percutaneous cardiac catheterization procedures can be readily implemented during clinical routine with low in-hospital complication rates.

0196: « Steb by step » expansion of Edwards SAPIEN XT prosthesis during transcatheter aortic valve implantation

To evaluate feasibility, safety and advantage of underexpansion of Edwards SAPIEN XT prosthesis during transcatheter aortic valve implantation (TAVI). We retrospectively analyzed 157 transfemoral TAVI procedures performed between October 2012 and December 2013 in the University Hospital of Rouen. Thirty-six (22.9%) patients had intentional underexpansion of the EDWARDS SAPIEN XT prosthesis since more than 20% area oversizing was anticipated with Computed tomography (CT) assessment of aortic annulus. Underexpansion of Edwards SAPIEN XT prosthesis was performed by reducing the volume of fluid within the valve deployment balloon. The Primary endpoint was aortic regurgitation (AR) at the end of the procedure. Mean age was 83.4±5.8 years and the mean logistic EuroSCORE of 15.4±9.6%. The initial fluid volume used for valve deployment was 90.1±3.1% of the theorical total volume (TTV) without significant difference among the 3 sizes of prostheses (90.2±4.1%, 89.5±2.6%, and 84.8±3.2% for 23, 26, and 29-mm valves, respectively). AR immediately after the first inflation was grade ≤I in 20 (55.6%) pts, grade II in 9 (25%) pts, and grade III in 7 (19.4%) pts. Stent diameter measured immediately after first inflation represented 94.2±4.1% of the prosthesis theorical diameter. Post-dilatation was deemed necessary in 14 cases (39.4%). At the end of the procedure, AR was < grade I in 34 (94.4%) patients and grade II in the 2 remaining patients. After post-dilatation, one patient presenting with fatal aortic annulus rupture. Other procedures were safe without stroke, myocardial infarction, or prosthesis migration. Our study suggest that underexpansion of Edwards SAPIEN-XT prosthesis is feasible during transfemoral TAVI procedures when more than 20% area oversizing is anticipated by CT. However, post-dilatation is mandatory in about 40% of cases to reduce significant residual aortic regurgitation but can be complicated by aortic annulus rupture

Access Site Practice and Procedural Outcomes in Relation to Clinical Presentation in 439,947 Patients Undergoing Percutaneous Coronary Intervention in the United Kingdom

This study sought to determine the relationships among access site practice, clinical presentation, and procedural outcomes in a large patient population. Transradial access (TRA) has been associated with improved patient outcomes in selected populations in randomized trials. It is unclear whether these outcomes are achievable in clinical practice. Using the BCIS (British Cardiovascular Intervention Society) database, we investigated outcomes for percutaneous coronary intervention procedures undertaken between 2007 and 2012 according to access site practice. Patients were categorized as stable, non-ST-segment elevation acute coronary syndrome (NSTEACS) and ST-elevation acute coronary syndrome (STEACS). The impact of access site on 30-day mortality, major adverse cardiac events, bleeding, and arterial access site complications was studied. Data from 210,260 TRA and 229,687 transfemoral access procedures were analyzed. Following multivariate analysis, TRA was independently associated with a reduction in bleeding in all presenting syndromes (stable odds ratio [OR]: 0.24, p < 0.001; NSTEACS OR: 0.35, p < 0.001; STEACS OR: 0.47, p < 0.001) as well as access site complications (stable OR: 0.21, p < 0.001; NSTEACS OR: 0.19; STEACS OR: 0.16, p < 0.001). TRA was associated with reduced major adverse cardiac events only in patients with unstable syndromes (stable OR: 1.08, p = 0.25; NSTEACS OR: 0.72, p < 0.001; STEACS OR: 0.70, p < 0.001). TRA was associated with improved outcomes compared with a transfemoral access (TFA) with a vascular closure device in a propensity matched cohort. In this large study, TRA is associated with reduced percutaneous coronary intervention-related complications in all patient groups and may reduce major adverse cardiac events and mortality in ACS patients. TRA is superior to transfemoral access with closure devices. Use of TRA may lead to important patient benefits in routine practice. TRA should be considered the preferred access site for percutaneous coronary intervention.

A Case of Local Groin Abscess Caused by Transfemoral Coronary Procedures

Bacterial infection due to coronary angiography is an uncommon but important complication of percutaneous coronary intervention (PCI) which is responsible for significant morbidity and extended hospital stay. The reasons for this symptom are still unclear. We report a case of local groin abscess two weeks after the latest procedure. The reasons responsible for the groin abscess in this case might be diabetes mellitus without being properly controlled, left ventricular (LV) systolic dysfunction, multiple operations in the same site, the usage of vascular closure device (VCD), and long time pressure after the procedure. We should pay enough attention to these risk factors in the future clinical practice to avoid this serious complication.

Abstract 20670: Coronary Microembolization During Transfemoral Transcatheter Aortic Valve Implantation: An Intracoronary Doppler Study

Background: A postprocedural increase of the serum troponin I concentration (TnI) reflects myocardial injury and occurs frequently during transcatheter aortic valve implantation (TAVI). Periprocedural coronary microembolization is a potential cause of such injury. We therefore evaluated each step of the transfemoral TAVI procedure for coronary embolization using intracoronary Doppler (ICD) in the left anterior descending (LAD) artery. Methods: 15 high-risk patients with severe, symptomatic aortic valve stenosis (age 79 ± 45 yrs; EuroScore 17 ± 4%) who underwent transfemoral TAVI using the balloon-expandable Edwards bioprosthesis were included. ICD examinations were recorded and evaluated off-line for high-intensity transient signals (HITS). Perioperative concentrations of TnI were serially measured within the first 72 h after TAVI, and a cardiac MRI with late gadolinium-enhancement (LGE) was performed within 7 days. Results: HITS were detected in all patients (figure 1), mostly during the initial crossing of the native valve and positioning of the prosthesis with subsequent implantation. TnI peaked at 24 h after TAVI (3.17 ng/ml), and LGE was observed in only one single case. There was no correlation between amount of HITS and TnI area under the curve in the first 72 h after TAVI. Conclusions: Procedural HITS were detected by ICD in all patients undergoing transfemoral TAVI. The highest amount of HITS was observed during initial valve passage and positioning of the prosthesis with subsequent implantation. However, no association was found between the number of HITS and myocardial injury, as reflected by increased serum TnI concentrations or LGE on cardiac MRI.